Association of Gabapentinoids With Opioid-Related Overdose in the Inpatient Setting: A Single Center Retrospective Case-Control Study.

Objectives: Recent data suggest concomitant gabapentinoid use increases opioid-related overdose (ORO) risk; however, this association has not been well studied in the hospital setting. The primary objective of this study was to compare ORO risk, indicated by naloxone administration, in patients receiving opioids plus gabapentinoids versus opioids alone. Methods: In this retrospective case-control study of adults admitted to a large community hospital from 1/1/20 to 12/31/21, all cases (defined as patients who received naloxone more than 24 hours after admission) identified were matched 1:1 to randomly selected controls (defined as patients on opioids who did not receive naloxone). The primary outcome was the percentage of cases and controls with concomitant inpatient gabapentinoid use. Logistic regression was performed to determine the independent association between gabapentinoids and ORO (as evidenced by inpatient naloxone administration). Results: Baseline characteristics were similar between the 144 cases and 144 controls. Gabapentinoid exposure was greater for cases than controls (34.0%vs 20.8%, P = .0118). Median hospital length of stay (11vs 4 days, P < .0001) and mortality (19%vs 5%; P = .0018) were also higher for cases. In logistic regression analysis, ORO (adjusted OR 4.91; 95% CI 1.86-12.96) and serotonergic medication exposure (adjusted OR 4.31; 95% CI 1.50-12.38) were significantly associated with gabapentinoid use. Conclusions: Concomitant gabapentinoid use with opioids was associated with increased ORO risk in the inpatient setting. When considering prescribing gabapentinoids in conjunction with opioids in the hospital setting, potential benefits should be weighed against increased overdose risk.

Community pharmacists' counseling regarding nicotine replacement therapy: A secret shopper study.

BACKGROUND: Nicotine replacement therapy (NRT) is a safe and effective non-prescription tobacco cessation treatment. While most community-based pharmacists periodically provide patient education regarding NRT, there is a gap in real-world evidence assessing the counseling provided. OBJECTIVES: To assess community pharmacist counseling regarding NRT in a real-world setting. METHODS: A cross-sectional secret shopper audit was conducted to collect data regarding NRT counseling from 120 community pharmacist encounters. Seventeen trained college of pharmacy students presented to community pharmacies using a standardized script asking about 1 of 3 common NRT products (patch, gum, and lozenge). Pharmacies were randomly selected from a list of all community pharmacies open to the public in Bexar County, Texas. A standardized assessment form was used to document product availability, counseling length, whether or not the 7 counseling points and 6 assessment questions that could help guide the pharmacist's counseling regarding NRT products were provided without prompting, and potential inaccuracy of any recommendations and counseling points. Descriptive statistics were calculated, and analysis of variance and Fisher's exact test were used to test for variation across site type and time of day. RESULTS: NRT was available for purchase without speaking to pharmacy staff in 99 of 120 (83%) pharmacies. The mean length of counseling was 136 (standard deviation = 91) seconds. The most common points discussed were recommended strength (72%), tapering schedule (58%), and assessment of the daily number of cigarettes smoked (56%). Forty-one (34%) pharmacists provided one or more potentially inaccurate counseling points, the most common being inaccurate tapering schedule (provided during 31 (26%) encounters). Only 15% of pharmacists referred auditors for additional help or recommended a follow-up. CONCLUSION: NRT was commonly accessible in community pharmacies outside of the pharmacy area. Opportunities for pharmacists to provide more complete and accurate information to better assist patients with safe and effective smoking cessation were identified.

Naloxone accessibility without an outside prescription from U.S. community pharmacies: A systematic review.

BACKGROUND: Recent evidence has identified limited naloxone accessibility in community pharmacies. OBJECTIVES: To summarize current literature regarding naloxone accessibility without an outside prescription from U.S. community pharmacies and discuss implications on community pharmacists' ability to mitigate the opioid overdose epidemic. METHODS: A systematic review was developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed was searched up to May 12, 2022. References from articles chosen for inclusion were subsequently reviewed to identify additional relevant studies. Peer-reviewed publications reporting new data regarding the accessibility of naloxone from U.S. community pharmacies without an outside prescription (e.g., standing order, protocol) were included. Review articles and articles written in a non-English language were excluded. Individual study data were reported, along with a qualitative discussion of limitations of individual studies and in aggregate. When possible, naloxone accessibility data were also pooled and reported as overall accessibility and further stratified by chain versus independent pharmacies and urban versus rural settings. RESULTS: Thirty studies were included. Naloxone was in stock in 6867 of 10,934 (62.8%) pharmacies, though this varied greatly between studies (range, 26.4%-96.1%). Chain pharmacies were more likely to stock naloxone than independents (69.7% [range, 35.4%-89.1%] vs. 36.4% [range, 19.1%-89.7%], P < 0.0001). Stocking did not significantly differ between urban and rural locations. A total of 5660 of 8999 (62.9%; range, 23.5%-97%) pharmacies audited were willing to dispense without a prescription, with chain (67.4% vs. 22.2%, P < 0.0001) and rural (69.3% vs. 40.7%, P < 0.0001) pharmacies more likely than independent and urban, respectively. Key access barriers identified included naloxone not stocked, high naloxone cost, and pharmacist misinformation or stigma. CONCLUSION: Though limited by study heterogeneity, analysis of thirty U.S. studies revealed naloxone was available without a prescription in less than two-thirds of community pharmacies. Availability varied significantly by study and pharmacy type.

Impact of a pharmacist-run refill and prior authorization program on physician workload.

BACKGROUND: Pharmacist-led programs centralizing prescription renewals and prior authorization processing have been implemented within health care systems; however, their impact on physician efficiency and the perception of impact on workload are unknown. OBJECTIVES: The primary objective of this study was to measure the change in physician efficiency score after implementation of the refill and prior authorization pilot program (RPAPP). Secondary objectives included changes in physician and staff perception of workload, changes in Center for Medicare and Medicaid Services (CMS) Star Measures, and program productivity. METHODS: This was a retrospective cohort study comparing patient and physician data 12 months before and after RPAPP implementation at an academic medical center. Physician efficiency was an average of 5 metrics that measure performance utilizing the electronic health record. Physician and staff perceptions were measured at baseline and 12 months via a pre- and postsurvey. Changes in CMS Star Measures were captured using the institution's Population Health Department data. RPAPP productivity was defined as the number of refills/prior authorizations processed and laboratory parameters ordered. RESULTS: On implementation, positive results were seen in average physician efficiency scores for 1 of 2 clinics (P < 0.05). Survey results indicated significantly positive changes in physician and staff perception of workload and satisfaction. The RPAPP appeared to help improve institutional performance for 2 of the 3 CMS Star measures evaluated (P < 0.05). CONCLUSION: Evaluation of primary care physician workload is complex. Although external variables may have impacted consistent results, the RPAPP appears to have positive effects on physician efficiency and satisfaction. These results may assist other health care institutions interested in initiating an RPAPP.

Polypharmacy prevalence in older adults seen in United States physician offices from 2009 to 2016.

BACKGROUND/OBJECTIVES: With an aging population suffering from increased prevalence of chronic conditions in the United States (U.S.), a large portion of these patients are on multiple medications. High-risk medications can increase the risk for drug-drug interactions and medication nonadherence. This study aims to describe the prevalence of polypharmacy and high-risk medication prescribing in U.S. physician offices. METHODS: This was a cross-sectional study of the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey from 2009 to 2016. All patients over 65 years old were included. Polypharmacy was categorized as no polypharmacy (< 2 medications), minor polypharmacy (2-3 medications), moderate polypharmacy (4-5 medications), and major polypharmacy (>5 medications). Medications were further categorized into high-risk medication categories (anticholinergics, cardiovascular agents, central nervous system (CNS) medications, pain medications, and other). Comparisons between the degrees of polypharmacy were performed utilizing chi-square or Wilcoxon rank-sum tests with JMP Pro 14® (SAS Institute, Cary, NC). RESULTS: Over 2 billion patient visits were included. Overall, Polypharmacy was common (65.1%): minor polypharmacy (16.2%), moderate polypharmacy (12.1%), and major polypharmacy (36.8%). Patients with major polypharmacy were older compared to those with moderate or minor polypharmacy (75 vs. 73 years, respectively) and were most frequently prescribed pain medications (477.3 per 1,000 total visits). NSAIDs were the most frequently prescribed, with 232.4 per 1,000 total visits resulting in one high-risk NSAID prescription, while 21.9 per 1,000 total visits resulted in two or more high-risk NSAIDs. CONCLUSION: Most patients over 65 years experienced some degree of polypharmacy, with many experiencing major polypharmacy. This indicates an increased need for expanded pharmacist roles through medication therapy management and safety monitoring in this patient population.